Residency · Residency · Obstetrics Gynecology
Total Laparoscopic Hysterectomy: Step-by-Step Approach
Introduction
Total laparoscopic hysterectomy (TLH) involves the complete removal of the uterus and cervix via laparoscopic technique, with vaginal extraction through a colpotomy. Minimally invasive hysterectomy (laparoscopic or vaginal) is recommended over abdominal hysterectomy whenever feasible per ACOG and AAGL guidelines. TLH offers reduced blood loss, shorter hospital stay, faster return to activity, and fewer wound complications compared to open abdominal hysterectomy.
Indications and Patient Selection
Common Indications
TLH is performed for symptomatic uterine leiomyomas refractory to medical management, abnormal uterine bleeding unresponsive to conservative therapy, endometriosis with extensive pelvic disease, pelvic organ prolapse (with concurrent vault suspension), endometrial hyperplasia with atypia or low-grade endometrial cancer, cervical dysplasia refractory to conservative management, and chronic pelvic pain with identifiable uterine pathology.
Contraindications to Laparoscopic Approach
Relative contraindications include very large uterus (greater than 16-20 weeks size, though morcellation or debulking extends this limit), extensive adhesive disease, and severe cardiopulmonary disease precluding Trendelenburg or pneumoperitoneum. Absolute contraindications include hemodynamic instability requiring emergent open surgery and known or suspected advanced malignancy where laparoscopy may compromise staging. The AAGL position holds that vaginal hysterectomy should be considered first, with TLH reserved for cases where the vaginal approach is not feasible.
Preoperative Preparation
Informed consent should address risks including conversion to laparotomy (2-5%), bladder injury (1-2%), ureteral injury (0.5-1%), bowel injury (0.3-0.5%), and hemorrhage requiring transfusion (1-2%). Preoperative imaging includes pelvic ultrasound for uterine size, fibroid location, and adnexal pathology, with MRI if uterine sarcoma is suspected. Mechanical bowel prep is not routinely required. DVT prophylaxis with sequential compression devices is standard, with pharmacologic prophylaxis for patients with additional risk factors. Antibiotic prophylaxis consists of cefazolin 2 g IV (3 g if 120 kg or greater) within 60 minutes of incision.
Step-by-Step Surgical Technique
Step 1: Access and Port Placement
A 10-12 mm umbilical trocar provides camera access via open, Veress, or optical entry. Two 5 mm lateral ports in the lower quadrants (lateral to the inferior epigastric vessels) and an optional suprapubic 5 mm port provide working access. A systematic survey of the upper abdomen, pelvis, and peritoneal surfaces identifies adhesions and anatomic landmarks.
Step 2: Uterine Manipulation
A uterine manipulator (Rumi, VCare, or equivalent) inserted through the cervix provides the colpotomy cup that delineates the vaginal fornix. Anteverted positioning facilitates initial dissection, with adjustments throughout the case for optimal exposure.
Step 3: Round Ligament Division
The round ligament is identified on each side, coagulated, and divided using bipolar electrosurgery with scissors or an advanced energy device. The broad ligament peritoneum is then opened anteriorly toward the vesicouterine fold and posteriorly toward the infundibulopelvic ligament.
<image>Intraoperative laparoscopic view showing the surgical anatomy during total laparoscopic hysterectomy with labeled structures including the round ligament (being divided), broad ligament, fallopian tube, ovary, infundibulopelvic ligament, uterine vessels, ureter, and bladder peritoneal reflection</image>
Step 4: Adnexal Management
If ovaries are preserved, the utero-ovarian ligament and fallopian tube pedicle are isolated and divided while maintaining distance from the ovarian blood supply. If bilateral salpingo-oophorectomy is performed, the infundibulopelvic (IP) ligament is isolated and the ureter is identified coursing medially on the pelvic sidewall before dividing the IP ligament. Opportunistic salpingectomy (removing tubes while preserving ovaries) is recommended per ACOG for ovarian cancer risk reduction.
Step 5: Bladder Flap Development
The vesicouterine peritoneal fold is identified and incised transversely. The bladder is sharply dissected off the lower uterine segment and cervix, mobilized at least 2 cm below the cervicovaginal junction. This step is essential for safe colpotomy and avoidance of bladder injury. Thermal energy should be avoided close to the bladder base.
Step 6: Uterine Artery Ligation
The uterine vessels are skeletonized at the level of the internal cervical os by creating a window in the posterior leaf of the broad ligament. The uterine artery and veins are coagulated and divided bilaterally. The ureter courses approximately 1.5-2 cm lateral to the internal cervical os and beneath the uterine artery ("water under the bridge"). The uterine artery pedicle is the most common source of hemorrhage during TLH.
Step 7: Cardinal and Uterosacral Ligament Division
Cardinal ligaments are divided at the level of the cervix using progressive coagulation and cutting while staying close to the cervix to avoid ureteral injury. Uterosacral ligaments are identified posteriorly, coagulated, and divided. These ligaments will be incorporated into the vaginal cuff closure for apical support.
Step 8: Colpotomy and Specimen Removal
A circumferential incision around the cervix is performed using monopolar scissors or an ultrasonic device, following the colpotomy cup for precise delineation. The uterus is delivered through the vagina. If too large for vaginal extraction, coring, bivalving, or contained power morcellation may be used. The FDA advises against open power morcellation; contained morcellation in an insufflated bag is an option when pathology permits.
Step 9: Vaginal Cuff Closure
The cuff is closed laparoscopically using barbed suture (V-Loc or Stratafix) in a continuous running technique or interrupted figure-of-eight sutures with delayed absorbable suture. Uterosacral ligaments are incorporated for apical support. Full-thickness bites include vaginal mucosa and fascial layers. Hemostasis is confirmed at all pedicles and the cuff.
Step 10: Final Assessment
Cystoscopy is performed with IV indigo carmine or 10% dextrose instillation to confirm bilateral ureteral jets and bladder integrity. The pelvis is irrigated and inspected for hemostasis. Fascia is closed at 10 mm or larger port sites.
<image>Sequential illustration of vaginal cuff closure during total laparoscopic hysterectomy showing running barbed suture technique incorporating the uterosacral ligaments at the lateral angles, with labeled needle bites through vaginal mucosa and fascial layers, demonstrating the completed closed cuff with apical support</image>
Postoperative Care
Enhanced recovery after surgery (ERAS) protocols include multimodal analgesia (scheduled NSAIDs, acetaminophen, gabapentin with minimized opioids), early oral intake, and early ambulation. Same-day discharge is feasible and safe for uncomplicated TLH. Activity restrictions include avoiding heavy lifting for 4-6 weeks and avoiding vaginal intercourse for 6-8 weeks until cuff healing is complete. Follow-up occurs at 2-4 weeks.
Complications
Vaginal cuff dehiscence occurs in 0.3-1% of TLH cases, higher than with abdominal or vaginal hysterectomy. Risk factors include smoking, intercourse before cuff healing, infection, and thermal injury during colpotomy. Hemorrhage may occur intraoperatively from the uterine artery, IP ligament, or vaginal cuff edges, or postoperatively from the vaginal vault. Ureteral injury (thermal, transection, or kinking) is identified by cystoscopy. Bladder injury is the most common urinary tract injury and is repaired in two layers with Foley drainage for 7-14 days.
Clinical Pearls
Always identify the ureter before dividing the infundibulopelvic ligament and uterine artery -- it lies at the medial leaf of the broad ligament, crossing under the uterine artery at the level of the internal os. Cystoscopy at the end of every hysterectomy is strongly recommended to identify ureteral and bladder injuries that might otherwise be missed. Barbed suture for cuff closure simplifies the technique and provides reliable closure; always incorporate uterosacral ligaments for apical support. Adequate bladder flap development is critical for safe colpotomy -- mobilize the bladder at least 2 cm below the vaginal fornix. ERAS protocols significantly improve recovery, reduce opioid use, and facilitate same-day discharge.
References
- AAGL Practice Report. Practice guidelines for the management of hysterectomy. J Minim Invasive Gynecol. 2014;21(2):166-170.
- ACOG Committee Opinion No. 701. Choosing the Route of Hysterectomy for Benign Disease. Obstet Gynecol. 2017;129(6):e155-e159.
- Aarts JWM, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015;(8):CD003677.
- Uccella S, Ceccaroni M, Cromi A, et al. Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of colpotomy and vaginal closure. Obstet Gynecol. 2012;120(3):516-523.
